A nurse on a hospice unit is caring for a client who has cancer and is in the active phase of dying. Which of the following findings requires intervention by the nurse?
An assistive personnel is encouraging intake of oral fluids.
Supplemental oxygen is in use.
Benzodiazepines are administered every 4 hr.
A family member remains at the client's bedside 24 hr each day.
The Correct Answer is A
A. An assistive personnel is encouraging intake of oral fluids: For a client in the active dying phase, forcing or encouraging oral intake can cause discomfort, aspiration, or fluid overload. The focus should be on comfort rather than meeting standard hydration goals, so this requires intervention by the nurse.
B. Supplemental oxygen is in use: Oxygen may be provided for comfort if the client experiences dyspnea. Its use in the active dying phase is appropriate and does not require intervention unless it causes discomfort or is unnecessary.
C. Benzodiazepines are administered every 4 hr: Scheduled benzodiazepines can help manage anxiety, restlessness, or dyspnea in a dying client. This is an appropriate intervention for comfort and does not require nurse intervention.
D. A family member remains at the client's bedside 24 hr each day: Continuous presence of family provides emotional support and comfort for both the client and loved ones. This is consistent with hospice care principles and does not require nurse intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for correct choices:
• N95 respirator: Mycobacterium tuberculosis is transmitted via airborne particles that remain suspended in the air. An N95 respirator is required to filter airborne droplet nuclei and protect the nurse from inhalation exposure. Standard surgical masks do not provide adequate airborne protection in confirmed TB cases.
• Gloves: As part of Standard Precautions, gloves should always be worn when there is a risk of contact with body fluids, such as sputum or contaminated surfaces in the client's room.
Rationale for incorrect choices:
• Surgical mask: A surgical mask protects against large respiratory droplets but does not filter airborne particles. TB requires airborne precautions, which exceed the level of protection provided by a standard mask. Surgical masks are more appropriate for droplet-based infections.
• Face shield: A face shield protects mucous membranes from splashes or sprays but does not filter inhaled air. TB does not spread via splashes, making this equipment unnecessary for routine airborne precautions. Respiratory protection remains the priority.
Correct Answer is B
Explanation
A. Client: The nurse should verify the client’s identity when administering any medication, but the client’s name is usually clearly stated in the prescription and is not ambiguous in this scenario. Clarifying the client is not the primary concern when reading back the prescription.
B. Route: The provider did not specify the route of administration (oral, intravenous, or sublingual), which is critical for safe medication administration. Clarifying the route ensures the nurse administers the drug correctly and avoids potential complications from using the wrong method.
C. Medication: The medication name, ondansetron, is clearly stated and unambiguous. There is no need for clarification unless there is a similar-sounding drug, which is not indicated in this scenario.
D. Dose: The dose of 4 mg every 6 hours as needed is clearly stated. The nurse does not need to clarify the dose since it is complete and within standard dosing guidelines for ondansetron.
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